Form SFN 22911 Motor Fuel Tax License Applicant - General Information - North Dakota

Form SFN22911 is a North Dakota Office of State Tax Commissioner form also known as the "Motor Fuel Tax License Applicant - General Information". The latest edition of the form was released in October 1, 2005 and is available for digital filing.

Download an up-to-date fillable Form SFN22911 in PDF-format down below or look it up on the North Dakota Office of State Tax Commissioner Forms website.

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MOTOR FUEL TAX LICENSE APPLICANT - GENERAL INFORMATION
NORTH DAKOTA OFFICE OF STATE TAX COMMISSIONER
SFN 22911 (10-2005)
All information must be complete and accurate - Attach addendum if additional space is needed
Section 1: Business identity
Business Name
Federal Employer Identifi cation Number (FEIN)
Corporate or Legal Name
Mailing Address (number and street, or post offi ce box)
City
State
ZIP Code
Telephone Number
Street Address of Business Headquarters (if different from mailing address)
City
State
ZIP Code
Location Where Business Records are Kept (if different from address of business headquarters)
City
State
ZIP Code
Section 2: Type of ownership - Check one




Sole Owner
Partnership
Limited Liability Partnership
Other



Corporation
Limited Partnership
Limited Liability Co.
Specify ______________
Section 3: Ownership information - Provide information for sole proprietorship, all partners,
all members of a limited partnership or a limited liability partnership, principal offi cers of
a corporation, or directors or governors of a limited liability company
Name (last, fi rst and middle initial)
Title
Social Security Number
Date of Birth
Home Address (number and street)
City
State
ZIP Code
Name (last, fi rst and middle initial)
Title
Social Security Number
Date of Birth
Home Address (number and street)
City
State
ZIP Code
Name (last, fi rst and middle initial)
Title
Social Security Number
Date of Birth
Home Address (number and street)
City
State
ZIP Code
North Dakota law provides that no foreign corporation or foreign limited liability company may conduct business in
this state or obtain any license or permit required by this state until it has procured a certifi cate of authority from
the secretary of state. North Dakota law also provides that no foreign limited partnership or foreign limited liability
partnership may conduct business in the state until it has registered with the secretary of state. (Questions regarding
certifi cates of authority and registrations should be directed to the North Dakota Secretary of State at 701.328.4284.)
List the state in which your company is organized
Enter the ID Number assigned to your business by the North Dakota Secretary of State or attach a copy of the Certifi cate of Authority
Section 4: Business status - Check one
New Business
Purchasing Existing Business
Change in Organizational Structure (sole ownership to corporation, etc.)
Change in Ownership
If you are purchasing an existing business, enter the name the business has been operating under
MOTOR FUEL TAX LICENSE APPLICANT - GENERAL INFORMATION
NORTH DAKOTA OFFICE OF STATE TAX COMMISSIONER
SFN 22911 (10-2005)
All information must be complete and accurate - Attach addendum if additional space is needed
Section 1: Business identity
Business Name
Federal Employer Identifi cation Number (FEIN)
Corporate or Legal Name
Mailing Address (number and street, or post offi ce box)
City
State
ZIP Code
Telephone Number
Street Address of Business Headquarters (if different from mailing address)
City
State
ZIP Code
Location Where Business Records are Kept (if different from address of business headquarters)
City
State
ZIP Code
Section 2: Type of ownership - Check one




Sole Owner
Partnership
Limited Liability Partnership
Other



Corporation
Limited Partnership
Limited Liability Co.
Specify ______________
Section 3: Ownership information - Provide information for sole proprietorship, all partners,
all members of a limited partnership or a limited liability partnership, principal offi cers of
a corporation, or directors or governors of a limited liability company
Name (last, fi rst and middle initial)
Title
Social Security Number
Date of Birth
Home Address (number and street)
City
State
ZIP Code
Name (last, fi rst and middle initial)
Title
Social Security Number
Date of Birth
Home Address (number and street)
City
State
ZIP Code
Name (last, fi rst and middle initial)
Title
Social Security Number
Date of Birth
Home Address (number and street)
City
State
ZIP Code
North Dakota law provides that no foreign corporation or foreign limited liability company may conduct business in
this state or obtain any license or permit required by this state until it has procured a certifi cate of authority from
the secretary of state. North Dakota law also provides that no foreign limited partnership or foreign limited liability
partnership may conduct business in the state until it has registered with the secretary of state. (Questions regarding
certifi cates of authority and registrations should be directed to the North Dakota Secretary of State at 701.328.4284.)
List the state in which your company is organized
Enter the ID Number assigned to your business by the North Dakota Secretary of State or attach a copy of the Certifi cate of Authority
Section 4: Business status - Check one
New Business
Purchasing Existing Business
Change in Organizational Structure (sole ownership to corporation, etc.)
Change in Ownership
If you are purchasing an existing business, enter the name the business has been operating under
SFN 22911 (10-2005)
Page 2
Section 5: Previous address - If the business headquarters moved during the last three years,
list the previous addresses (this does not apply if it is a new business)
Address (number and street)
City
State
Address (number and street)
City
State
Section 6: Previous association with motor fuels sales or distribution
Are you now or have you ever been associated with any other individual, company, corporation, limited liability
company, partnership, limited partnership, or limited liability partnership, which has or has had an interest in the
sale or distribution of motor fuels?
Yes ____
No ____
If yes, provide the following information:
Name of Person to Contact
Title
Name of Business
Address (number and street)
City
State
ZIP Code
In what capacity were you or are you involved?
Section 7: Financial statement
Submit a copy of your most recent income statement and statement of assets and liabilities.
Section 8: Financial institutions
Name of your Company's Financial Institution
Account Number
Address (number and street or post offi ce box)
City
State
ZIP Code
Name of your Company's Financial Institution
Account Number
Address (number and street or post offi ce box)
City
State
ZIP Code
Section 9: Type of licenses - Check the applicable license types
Motor vehicle fuel
Special fuel
Liquefi ed petroleum
Aviation fuel
Section 10: Names and titles of contact persons such as managers, accountants, tax return
preparers
Name
Title
Telephone Number
Name
Title
Telephone Number
Name
Title
Telephone Number
Section 11: Authorized signature
I declare under the penalties of North Dakota Century Code § 12.1-11-02, which provides for a Class A misdemeanor
for making a false statement in a governmental matter, that this general information statement has been examined
by me and to the best of my knowledge and belief is complete, correct, and true.
Name of Owner or Authorized Offi cer (print or type)
Title
Signature of Owner or Authorized Offi cer
Date
Instructions for Fuel Tax License Applicants
Motor vehicle fuel tax, special fuel tax, liquefi ed petroleum gas tax, and aviation fuel tax licenses are required. A
refi ner, terminal operator, supplier, distributor, importer, exporter, and also a special fuel or liquefi ed petroleum retailer,
must obtain applicable licenses from the Tax Commissioner prior to conducting business in North Dakota. The law does
not provide for the licensing of motor vehicle fuel and aviation fuel retailers.
Registration with the Secretary of State, may be required. For information, visit the Secretary of State web site at
www.nd.gov/sos.
Separate Fuel Tax Licenses Required
Motor vehicle fuel tax license:
A motor vehicle fuel tax license covers gasoline, gasohol (gasoline/alcohol/ethanol blend, including E85), ethanol or
alcohol sold for blending with gasoline, natural gasoline, [casinghead (absorption) gasoline, condensate, or drip gasoline
when blended with gasoline or sold for blending with gasoline], and racing fuel (high octane gasoline, high octane
gasoline blend, or methanol).
Special fuel tax license:
A special fuel tax license covers undyed (not dyed red) diesel, dyed (red) diesel, heating fuels, kerosene, compressed
natural gas, waste oil used as heating fuel, and any other combustible products not otherwise classifi ed as a motor vehicle
fuel, liquefi ed petroleum gas, or aviation fuel. It does not include motor oils or other heavy grade (#5 or #6) fuels.
Liquefi ed petroleum gas tax license:
A liquefi ed petroleum gas tax license covers propane.
Aviation fuel tax license:
An aviation fuel tax license covers jet fuel, kerosene (if sold for use in aircraft), aviation gasoline, regular gasoline (if sold
for use in aircraft), and any other fuel sold for use in aircraft.
An aviation fuel tax license will not be required if the seller makes only occasional sales of 1,000 gallons or less in a
month. That seller will be considered a “retailer only.”
Categories for Licenses
Licensing categories defi ned:
“Refi ner” means a person who produces, manufactures, or refi nes...fuel in this state for resale to a consumer.
“Terminal operator” means a person who by ownership or contractual agreement is charged with the responsibility for,
or physical control over, and operation of a terminal. If a terminal is owned by coventurers, “terminal operator” means the
person appointed to exercise the responsibility for, or physical control over, and operation of the terminal.
“Supplier” means a refi ner who distributes...fuel from a terminal in this state, or any person who acquires...fuel by
pipeline from a state, territory, or possession of the Unites States or from a foreign country, for storage at and distribution
from a terminal, or a person who acquires...fuel by truck or railcar for storage at and distribution from a terminal in this
state.
NOTE: A “supplier” sells fuel across the rack at a terminal.
“Distributor” means a person, other than a retailer, who acquires...fuel from a supplier for subsequent wholesale
distribution in bulk or transport load by truck, railcar, or in a barrel, drum, or other receptacle.
1
NOTE: A “distributor” includes: (1) a marketer; (2) a wholesaler who purchases fuel from another wholesaler or from
a distributor; (3) a person who makes bulk delivery sales; and (4) a “retailer only” who is also an “importer.”
“Importer” means a refi ner, supplier, or distributor who imports...fuel into this state in bulk or transport load by truck,
railcar, or in a barrel, drum, or other receptacle. “Import” means the delivery of...fuel across the boundaries of this
state from a place of origin outside this state by a refi ner, supplier, or distributor.
NOTE: An “importer” takes legal possession of fuel in another jurisdiction and brings it into North Dakota for resale.
“Legal possession” is determined based on a change in ownership.
NOTE: An “importer” must be licensed as an “exporter” in the jurisdiction in which the fuel was acquired for export,
unless that jurisdiction does not require a license.
“Exporter” means a refi ner, supplier, or distributor who exports...fuel out of this state in bulk or transport load by
truck, railcar, or in a barrel, drum, or other receptacle. “Export” means the delivery of...fuel across the boundaries of
this state from a place of origin in this state by or for a refi ner, supplier, or distributor.
NOTE: An “exporter” relinquishes legal possession of the fuel in another jurisdiction. “Legal possession” is
determined based on a change in ownership.
NOTE: An “exporter” must be licensed as an “importer” in the jurisdiction to which the fuel is taken for resale, unless
that jurisdiction does not require a license.
“Retailer” means a person who acquires...fuel from a supplier or a distributor for resale to a consumer at a retail
location. “Retail location” means a site at which...fuel is dispensed through a pump from an underground or
aboveground storage unit into the supply tank of...[a motor vehicle, aircraft].
Additional information about categories:
“Retail only,” for licensing purposes, means all sales are made at a retail location. The fact that a business is
generically considered to be a “retail” business is not material.
For aviation fuel, “retail location” means a site at an airport at which aviation fuel is dispensed from an underground
or aboveground storage unit, or from a fuel delivery tank unit, directly into the supply tank of an aircraft.
For liquefi ed petroleum gas, a retailer is a person who fuels licensed motor vehicles with propane at a retail location
or similar site. A retailer selling fi lled propane cylinders to consumers, but not dispensing propane into fuel supply
tanks of licensed vehicles, has the following options:
a. Obtain a license.
b. Be considered a consumer. With this option the retailer is not licensed and pays the 2% special fuel excise tax to
a distributor or supplier.
A person other than a refi ner, supplier, distributor, or retailer selling fi lled propane cylinders to consumers, will always
be treated as a “consumer.” The supplier or distributor selling propane to that person must charge and remit the 2%
special fuel excise tax.
For special fuel, a “retailer only” has the following options:
a. Apply for a license and post a minimum $1,000 security. With this option, fuel may be purchased either tax
free or tax paid. A monthly report and applicable schedules are required.
2
b. Request an inactive license. With this option, the licensee must pay the per gallon tax to a supplier or distributor
on all purchases and may not make bulk delivery sales. The Tax Commissioner will suspend the mandatory
security requirement as long as the license remains inactive, and monthly reports will not be required.
If the licensee wants to purchase fuel tax free or make bulk deliveries, the license must be made “active,” a
security must be provided, and monthly reports will be required.
Application – General Information
Section 1 – Business identity:
Enter your business name. If you have a corporate or legal name different from the entry under business name, enter
that name. Provide your Federal Employer Identifi cation Number (FEIN). This number is issued by the Internal
Revenue Service and is required for all employers withholding Federal income taxes. It is also the Federal registration
number required by all corporations. If you do not have a number, you may obtain an application form by writing to an
IRS offi ce or by calling them toll free at 1-800-829-3676. If you are not required to obtain a number and do not intend
to apply for a number, the Motor Fuel Tax Section will assign a tax account number for exclusive use as your fuel tax
identifi cation number.
Provide your mailing address, the address of your business or corporate headquarters, and the address where your
records will be available should your account be selected for an audit. If the address is the same for all three, enter the
address only once.
Section 2 – Type of ownership:
Check the type of ownership for your business operation.
Section 3 – Ownership information:
Provide the required information.
Foreign corporation, foreign limited liability company, foreign limited partnership, foreign limited liability
partnership: A certifi cate of authority, or authorization of registration, from the North Dakota Secretary of State is
required before a fuel tax license may be issued. Provide the state in which your business is organized, and provide
the identifi cation number assigned by the North Dakota Secretary of State (you may attach a copy of the Certifi cate of
Authority if you are not certain of the number).
Section 4 – Business status:
Check the applicable box.
If you are purchasing an existing business, enter the name used by that business.
Section 5 – Previous address:
If your business headquarters moved during the last three years, enter the previous addresses.
Section 6 – Previous association:
Complete this section if you have ever been associated with another person in the fuel sales and distribution business.
Section 7 – Financial statement:
Submit a copy of a statement showing the assets and liabilities of the business venture covered by the application.
Section 8 – Financial institutions:
Provide information about the banks or other fi nancial institutions used or to be used for your business purposes.
Section 9 – Type of license:
Check every type of license for which you are making an application.
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Download Form SFN 22911 Motor Fuel Tax License Applicant - General Information - North Dakota

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